“I’m waiting for my permit but it’s not coming, I might as well die here,” Mariam Qaloub said from her bed at Abdel Aziz al Rantisi hospital in Gaza where thousands of cancer patients are treated. The 60-year-old woman is being treated for cancer. Her family said she was able to exit the Gaza Strip twice to receive two sessions of chemotherapy. She now needs medication after a relapse of the disease.

“Her drugs are not available anymore, as a result she’s more tired than ever, and she can’t walk,” says her daughter-in-law, Manal. The family applied for a permit about a month ago, she explains. Since then, the permit application has been pending.

“The doctors are doing their best, really, but they can’t do magic,” Mariam’s daughter, Hind Qaloub, said. She comes every day to visit her mother and she says that she is always hoping for her to sleep as “without the medication, she’s really in great pain, and there’s nothing we can do.”Even though she has been told the delays in obtaining permits to exit the Gaza Strip for treatment are “political”, “it does not make sense to me: what will the death of my mother change about Palestinian or Israeli politics?” she asks.Stories like these are more and more common in the Gaza Strip. The general situation of the healthcare system is already appalling: medication shortages, lack of equipment and medical staff, electricity crisis impacting how surgery rooms work… Among the most notable problems, there’s absolutely no radiotherapy available in the Gaza Strip. The equipment needed for such treatment was prevented to reach the Strip by Israeli authorities for “security reasons” and fear it would be used by the military wing of Hamas. This problem is even more serious considering that according to the local Ministry of Health, around two-thirds of the 7,000 cancer patients in the Gaza Strip require radiotherapy treatment.

Medical Aid for Palestinians, a British NGO with a strong presence in the Strip, warned last week that "the situation in Gaza has reached its lowest ebb outside of periods of military attack and should now be considered a humanitarian emergency." Electricity shortages that﻿ have left the Strip with daily blackouts of 18-20 hours have had a detrimental impact on its already strained healthcare system.

Relatives of patient Mariam Qaloub during a visit at Rantisi hospital in the Gaza Strip

As the situation is so dysfunctional, many patients need to be referred to hospitals outside of the Gaza Strip, most of the time in East Jerusalem, in order to get the proper treatment. The process is very tedious. A doctor from the Gaza Strip will file an application explaining what the patient needs. This application goes to the office in charge of referrals in Gaza (Service Purchasing Unit - SPU), where a medical committee reviews it. Once approved by this first round of experts, the application is sent online through a platform that the World Health Organization set up in 2015 (the former system implied fax and phone calls and was leading to constant mistakes and delays).The SPU in Ramallah –affiliated with the Palestinian Ministry of Health- receives it and looks into it one more time, evaluating which would be the most suitable hospital for the patient to get treatment. They approve the application and decide on a “receiving hospital” that could offer the adequate treatment. This Ramallah-based office also coordinates for financial coverage, setting up a budget for the treatment.The SPU in Gaza then gets in touch with the healthcare facility and requests an appointment for the patient. At that point, it’s more and more common that a lot of facilities would actually answer that they have no availability or they lack beds or medicine as they are in high demand – in that case, the SPU needs to look for other facilities that could offer the treatment. Once a facility answers positively, and an appointment date is set, the patient can apply for an exit permit through the Palestinian Health Liaison Office (HLO) based in Gaza, for the set date.The Israeli Coordination and Liaison Administration Office (CLA) processes each application and coordinates with the HLO. The patient waits to receive a text message from HLO, which usually comes a day before the appointment. Once they get the text, they go pick up their permits and they can cross through Erez checkpoint to reach the hospital, get treated, and come back to the Gaza Strip.There is a fast-track for urgent cases such as neonatology ones, and another one for regular cases.
This whole process is very commonly used; for instance in 2016, 24,616 people were referred to hospitals outside of the Gaza Strip, out of these 19,877 applied for an exit permit. More than half got treated in East Jerusalem, some in the West Bank, some in Israel, others in Egypt and very few in Jordan (only 26).
Between January and July, 16,000 patients and escorts have been allowed to leave for hospitals outside the Gaza Strip.The World Health Organization said that Israel delayed about half of the applications of patients who needed to be treated in Israeli hospitals in April and May; they expect similar statistics for the months after that (data is not available yet).This is a very significant problem explains the staff of Physicians for Human Rights in Israel (PHRI)–an organization that deals with patients and referrals in the Gaza Strip. Ran Goldstein, head of PHRI, said “there must be a drastic change in Israeli policy toward the exit of patients (…). The fact that patients sometimes don’t get answers for months is cruel and the weakest population pays the price.” Interviewed by Israeli daily newspaper Haaretz, the CLA answered that “some 400 people are allowed to enter (Israel) daily for medical needs and a variety of other reasons,” justifying the delays in granting exit permits with security concerns over Hamas members in the Gaza Strip.Despite these statements, it was confirmed by all organizations working on medical issues in the Gaza Strip –including the WHO - that 2016 was an all-time low for exit permits since 2008: only 62% of the applications were answered positively (compared to 92.5% in 2012 for instance).The Israeli human rights organization B'Tselem issued a statement based on a 2016 report highlighting the lack of transparency of the process for the exit permits to be granted: “as a rule, Israeli authorities permit patients to enter Israel for medical care only in life-and-death cases. Although permits are sometimes granted to people suffering from severe but non-life threatening conditions, even then the treatment is sometimes cut short because authorities refuse to issue additional permits. (…) The criteria for issuing permits for what Israel calls “quality of life” medical care are unknown. This leaves patients in a constant state of uncertainty.”Health Minister Jawad Awwad confirmed the seriousness of the situation: “since the beginning of the year, Israel has hindered several medical referrals for sick Gazans; we have tried to contact them through the Israeli civil administration but we have not gotten any results.”Concerned with the general situation, the organization has been fundraising to improve the services available inside the Gaza Strip, waiting for the permits issue to be solved. In June, they were able to raise 85,000 dollars.All the international organizations working in the Palestinian territories (including UN agencies) launched a humanitarian appeal for the Gaza Strip in early July. They asked for 25 million dollars, and only 24% of the total amount has been secured so far.

Simultaneously to this phenomenon, human rights organizations in the Gaza Strip, such as al-Mezan that helps patients to appeal decisions when they don’t get exit permits, said the number of referrals approved by the SPU in Ramallah significantly dropped over the past months.

“It’s only thanks to NGOs that we are able to keep the patients alive,” said Dr. Mohammad Salmiyya, head of the Abdel Aziz al Rantisi hospital in Gaza where Mariam Qaloub is being treated. “We are talking about people lives, and it’s no game,” he added.Patients are not the only segment of population to be denied crossing through Erez. Last week, even Kamal Sherafi, human rights advisor to Palestinian President Mahmoud Abbas, was barred from leaving Gaza by the Israeli authorities. He stated in solidarity with patients that: “even sick Gazans who have a permit to travel to West Bank hospitals and even Israeli hospitals for treatment are denied exit sometimes. Freedom of movement is not a right given to us by the Israeli authorities.”